Soap note Study guides, Class notes & Summaries

The ability to bounce back or cope in the face of adversity is known as correct answer: Resilience. Research has shown that the most powerful way to reduce stigma associated with behavioral health disorders is correct answer: Contact. One technique that can help boost confidence and encourage peers to stretch their comfort zones in relationship building is: correct answer: role playing. The most common factor in increasing resilience is correct answer: a caring relationship The a...

what is the primary function of a medical scribe? - create the medical note what is the preferred format for the creation of the medical note? - subjective, objective, assessment, plan (soap) "present time" pt details are summarized by using what format - OPQRST all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms - international classification of disease (ICD) what patient history is outlined in the PMHx - medical history what scribing i...

WOMEN’S HEALTH MINI SOAP NOTES A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect? 1 Candidiasis 2 Trichomoniasis 3 Bacterial vaginosis 4 Group B Streptococcus - ANS -Bacterial vaginosis Signs of bacterial vaginosis include a milky gray vaginal...

HEENT SOAP NOTE with complete solution HEENT SOAP NOTE Jewel Concepcion United States University MSN 572 Advanced Physical Assessment Dr. Sherian Wilmot-Carter March 27, 2023

NURS 3150 soap note Fall 2023 Subjective Data A. Chief Complain (CC): “I need a primary care doctor and I also have an injury to my toe” B. History of Present Illness (HPI): C. Last Menstrual Period– Not applicable. D. Allergies: NKDA E. Past Medical History: Hypertension and diabetes II F. Family History: Father – Diabetes and Glaucoma Mother – Hypertension G. Surgery History- None H. Social History- Denies drug use, alcohol and tobacco use, Erickson developmental stage...

:Section 1 Patient Initials: J.A. Age: 58 y/o Gender: Male Race: Caucasian ”.Chief complaint: “I’ve been having some chest discomfort · :HPI · OLDCARTS o J.A. is a 58 y/o healthy man presenting to care provider with a o complaint of recent episodes of burning chest discomfort X 4 days. Rating substernal pain 4-5/10 at its worst, radiating into his neck. Current pain of 1-2/10. Borderline-obese. Well controlled HTN, on Lopressor, and borderline lipid abnormality. Recent stres...

Name: Carolyn Cross Date: 3/18/2017 Time: 21:00am elmdtn Patient Encounter # 4140505 Age: 41 years Sex: Female CC: This 41-year-old male presents a chronic cough. She said, “My throat is painful, I cough frequently. There seems to be nothing to relieve it when I started to cough.” HPI: Carolyn Cross confirms that coughing started almost four weeks ago after failing to wear a sweater, during one cold morning when attending a job. Carolyn Cross added that chronic coughing started one wee...

NRNP 6552 Wk3Assgn2,Case study (Walden university) Case Study 2 Case Study: STI Investigation Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full- time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH ...

NRNP 6665 Assignment 2 Focused SOAP Note and Patient Case Presentation, NRNP 6665 PMHNP Care Across the Lifespan I, Walden University.

EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+ SOap Note Blue Print Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt: Info Source: Patient Reliability: Reliable E&M Code(s) I.10 S CC: Elevated blood pressure HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier and it was high, my wife convinced me to come in.” Patient describes a...